PAR-Q Form

First Name

Last Name

Height

Gender

Age

Weight

Please read through the following questions carefully and answer next to the one that is appropriate for you. Answer all questions honestly.

Yes or No Questions

Rows	Yes	No
When visiting your doctor have they ever said you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?
Within the last month have you ever experienced chest pain while doing exercise?
Do you ever feel pain in your chest after doing exercise?
Do you ever suddenly become dizzy or lose consciousness?
When visiting the doctor have you ever been told you have bone, joint or muscle problems that can be made worse by completing exercise?
Do you have a diagnosed illness that can be made worse by doing physical exercise?
Are you being prescribed medication for blood pressure or a heart condition currently?
Do you know any reasons why you shoudnt be doing physical exercise?

1. What is your goal?

2. How would you rate your current nutrition?

1 is Worst, 5 is Best

3. How would you rate your current fitness levels?

1 is Worst, 5 is Best

4. How can I help you achieve your goals?

5. Have you had any injuries or pain problems? (Hip, ankle, lower back etc) (if yes, please explain)

6. Have you had any surgeries? (If yes, please explain)

7. Has your doctor ever diagnosed you with a chronic disease? Such as coronary heart disease, high blood pressure or diabetes. (If yes, please explain)

8. Are you currently taking any medication? (If so, please explain)

By signing below, I understand the risks of physical activity and confirm the information provided is accurate.

Date

Participant name:

Emergency contact number?

Emergency contacts name and relationship to you?